ONL:HU NSG120 Pathophysiology Exam 1
2025 Fall C - Herzing University HESI
1. The nurse is caring for an immobilized client who is at "Risk for alterations
in skin integrity." Which pathophysiological process should the nurse note
early in the development of a pressure injury?
• A. Ischemic inflammatory response marked by erythema
• B. Hypovolemia fluid accumulation and blister formation
• C. Epidermal fragility and skin excoriation with serous drainage
• D. Necrotic tissue, purulent exudate and eschar formation
Correct Answer: A
Rationale: The earliest pathophysiological change in pressure injury development
is ischemia and inflammation, which presents as non-blanchable erythema (A).
Blisters (B) occur later; necrosis and eschar (D) are late findings.
2. The nurse identifies an electrolyte imbalance, an elevated central venous
pressure, and generalized edema for a client with full thickness burns. Which
intervention should the nurse implement?
• A. Auscultate for irregular heart rate.
• B. Monitor daily sodium intake.
• C. Record usual eating patterns.
• D. Document abdominal girth.
Correct Answer: A
Rationale: Electrolyte imbalances (especially potassium) and fluid overload
(elevated CVP, edema) increase the risk of cardiac dysrhythmias. Auscultating for
irregular heart rate (A) is the priority to detect life-threatening dysrhythmias.
Sodium intake (B) and eating patterns (C) are not immediate concerns; abdominal
girth (D) is less specific.
3. While changing the dressing of an immobile client, the nurse observes a red
and swollen wound with a moderate amount of yellow and green drainage
, with a foul odor. Given there is a possible methicillin-resistant
Staphylococcus aureus (MRSA) laboratory result, which action is the most
important for the nurse to take?
• A. Administer prescribed antibiotics.
• B. Report the findings to the healthcare provider.
• C. Drain the axillaries at once and apply a new dressing.
• D. Initiate contact precautions.
Correct Answer: D
Rationale: MRSA is highly contagious and requires contact precautions (D) to
prevent spread to other patients and staff. Antibiotics (A) and reporting (B) are
important but secondary to immediate infection control.
4. During the shift change report, the nurse is told that a client has a stage 2
pressure injury. Which pressure injury appearance is most likely to be
observed?
• A. Visible subcutaneous tissue with sloughing
• B. A deep pocket of infection and necrotic tissues
• C. Shallow open wound with a red pink wound bed
• D. An area of erythema that is painful to touch
Correct Answer: C
Rationale: Stage 2 pressure injury is a partial-thickness skin loss presenting as
a shallow open ulcer with a red-pink wound bed (C) without slough or bruising.
Subcutaneous tissue (A) is stage 3; deep pocket (B) suggests stage 4 or
unstageable; erythema (D) is stage 1.
5. A client with severe burns develops a sudden drop in blood pressure and
decreased urine output. Which pathophysiological mechanism is the primary
cause?
• A. Increased capillary permeability and hypovolemia
• B. Myocardial depression from circulating toxins
• C. Adrenal insufficiency from cortisol depletion
• D. Bacterial translocation causing septic shock
,Correct Answer: A
Rationale: In the early phase after major burns, systemic capillary leak leads to
massive fluid shift from intravascular to interstitial space, causing hypovolemia
and hypotension (A). Myocardial depression (B) occurs later; adrenal
insufficiency (C) is not the primary cause; sepsis (D) occurs later.
6. A client with a head injury has a PaCO₂ of 55 mm Hg. Which acid-base
imbalance should the nurse expect?
• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis
Correct Answer: A
Rationale: PaCO₂ >45 mm Hg indicates hypercapnia, which causes respiratory
acidosis (A) due to hypoventilation. Respiratory alkalosis (B) would have low
PaCO₂; metabolic imbalances (C, D) involve changes in bicarbonate.
7. Which laboratory finding is most consistent with acute pancreatitis?
• A. Elevated serum amylase and lipase
• B. Decreased serum calcium
• C. Elevated liver transaminases
• D. Increased blood urea nitrogen
Correct Answer: A
Rationale: Elevated serum amylase and lipase (A) are the hallmark laboratory
findings in acute pancreatitis, typically 3-fold above normal. Hypocalcemia (B)
may occur but is not diagnostic; transaminases (C) suggest liver disease; BUN (D)
is non-specific.
8. A client with chronic kidney disease has a serum potassium of 6.8 mEq/L.
Which electrocardiographic change should the nurse anticipate?
• A. Peaked T waves
• B. Prominent U waves
• C. Prolonged PR interval
, • D. ST segment elevation
Correct Answer: A
Rationale: Hyperkalemia (K⁺ >6.0 mEq/L) classically causes peaked, narrow T
waves (A). Prominent U waves (B) are seen in hypokalemia; prolonged PR
interval (C) occurs in hyperkalemia but is not the earliest sign; ST elevation (D) is
not typical.
9. Which finding differentiates hypovolemic shock from cardiogenic shock?
• A. Decreased cardiac output
• B. Tachycardia
• C. Cool, clammy skin
• D. Decreased central venous pressure
Correct Answer: D
Rationale: In hypovolemic shock, central venous pressure (CVP) is decreased
(D) due to low preload; in cardiogenic shock, CVP is elevated due to pump failure.
Both can have decreased cardiac output (A), tachycardia (B), and cool skin (C).
10.A client with cirrhosis develops ascites. Which pathophysiological
mechanism contributes most directly to ascites formation?
• A. Increased portal pressure and low serum albumin
• B. Decreased aldosterone secretion
• C. Increased antidiuretic hormone (ADH) release
• D. Hepatic artery vasodilation
Correct Answer: A
Rationale: Portal hypertension (increased portal pressure) and
hypoalbuminemia (low serum albumin) (A) cause fluid to leak into the
peritoneal cavity. Aldosterone is increased, not decreased (B); ADH (C)
contributes but is secondary; hepatic artery vasodilation (D) is part of
hyperdynamic circulation.
11.Which type of shock is most commonly associated with anaphylaxis?
• A. Hypovolemic shock
• B. Cardiogenic shock
2025 Fall C - Herzing University HESI
1. The nurse is caring for an immobilized client who is at "Risk for alterations
in skin integrity." Which pathophysiological process should the nurse note
early in the development of a pressure injury?
• A. Ischemic inflammatory response marked by erythema
• B. Hypovolemia fluid accumulation and blister formation
• C. Epidermal fragility and skin excoriation with serous drainage
• D. Necrotic tissue, purulent exudate and eschar formation
Correct Answer: A
Rationale: The earliest pathophysiological change in pressure injury development
is ischemia and inflammation, which presents as non-blanchable erythema (A).
Blisters (B) occur later; necrosis and eschar (D) are late findings.
2. The nurse identifies an electrolyte imbalance, an elevated central venous
pressure, and generalized edema for a client with full thickness burns. Which
intervention should the nurse implement?
• A. Auscultate for irregular heart rate.
• B. Monitor daily sodium intake.
• C. Record usual eating patterns.
• D. Document abdominal girth.
Correct Answer: A
Rationale: Electrolyte imbalances (especially potassium) and fluid overload
(elevated CVP, edema) increase the risk of cardiac dysrhythmias. Auscultating for
irregular heart rate (A) is the priority to detect life-threatening dysrhythmias.
Sodium intake (B) and eating patterns (C) are not immediate concerns; abdominal
girth (D) is less specific.
3. While changing the dressing of an immobile client, the nurse observes a red
and swollen wound with a moderate amount of yellow and green drainage
, with a foul odor. Given there is a possible methicillin-resistant
Staphylococcus aureus (MRSA) laboratory result, which action is the most
important for the nurse to take?
• A. Administer prescribed antibiotics.
• B. Report the findings to the healthcare provider.
• C. Drain the axillaries at once and apply a new dressing.
• D. Initiate contact precautions.
Correct Answer: D
Rationale: MRSA is highly contagious and requires contact precautions (D) to
prevent spread to other patients and staff. Antibiotics (A) and reporting (B) are
important but secondary to immediate infection control.
4. During the shift change report, the nurse is told that a client has a stage 2
pressure injury. Which pressure injury appearance is most likely to be
observed?
• A. Visible subcutaneous tissue with sloughing
• B. A deep pocket of infection and necrotic tissues
• C. Shallow open wound with a red pink wound bed
• D. An area of erythema that is painful to touch
Correct Answer: C
Rationale: Stage 2 pressure injury is a partial-thickness skin loss presenting as
a shallow open ulcer with a red-pink wound bed (C) without slough or bruising.
Subcutaneous tissue (A) is stage 3; deep pocket (B) suggests stage 4 or
unstageable; erythema (D) is stage 1.
5. A client with severe burns develops a sudden drop in blood pressure and
decreased urine output. Which pathophysiological mechanism is the primary
cause?
• A. Increased capillary permeability and hypovolemia
• B. Myocardial depression from circulating toxins
• C. Adrenal insufficiency from cortisol depletion
• D. Bacterial translocation causing septic shock
,Correct Answer: A
Rationale: In the early phase after major burns, systemic capillary leak leads to
massive fluid shift from intravascular to interstitial space, causing hypovolemia
and hypotension (A). Myocardial depression (B) occurs later; adrenal
insufficiency (C) is not the primary cause; sepsis (D) occurs later.
6. A client with a head injury has a PaCO₂ of 55 mm Hg. Which acid-base
imbalance should the nurse expect?
• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Metabolic acidosis
• D. Metabolic alkalosis
Correct Answer: A
Rationale: PaCO₂ >45 mm Hg indicates hypercapnia, which causes respiratory
acidosis (A) due to hypoventilation. Respiratory alkalosis (B) would have low
PaCO₂; metabolic imbalances (C, D) involve changes in bicarbonate.
7. Which laboratory finding is most consistent with acute pancreatitis?
• A. Elevated serum amylase and lipase
• B. Decreased serum calcium
• C. Elevated liver transaminases
• D. Increased blood urea nitrogen
Correct Answer: A
Rationale: Elevated serum amylase and lipase (A) are the hallmark laboratory
findings in acute pancreatitis, typically 3-fold above normal. Hypocalcemia (B)
may occur but is not diagnostic; transaminases (C) suggest liver disease; BUN (D)
is non-specific.
8. A client with chronic kidney disease has a serum potassium of 6.8 mEq/L.
Which electrocardiographic change should the nurse anticipate?
• A. Peaked T waves
• B. Prominent U waves
• C. Prolonged PR interval
, • D. ST segment elevation
Correct Answer: A
Rationale: Hyperkalemia (K⁺ >6.0 mEq/L) classically causes peaked, narrow T
waves (A). Prominent U waves (B) are seen in hypokalemia; prolonged PR
interval (C) occurs in hyperkalemia but is not the earliest sign; ST elevation (D) is
not typical.
9. Which finding differentiates hypovolemic shock from cardiogenic shock?
• A. Decreased cardiac output
• B. Tachycardia
• C. Cool, clammy skin
• D. Decreased central venous pressure
Correct Answer: D
Rationale: In hypovolemic shock, central venous pressure (CVP) is decreased
(D) due to low preload; in cardiogenic shock, CVP is elevated due to pump failure.
Both can have decreased cardiac output (A), tachycardia (B), and cool skin (C).
10.A client with cirrhosis develops ascites. Which pathophysiological
mechanism contributes most directly to ascites formation?
• A. Increased portal pressure and low serum albumin
• B. Decreased aldosterone secretion
• C. Increased antidiuretic hormone (ADH) release
• D. Hepatic artery vasodilation
Correct Answer: A
Rationale: Portal hypertension (increased portal pressure) and
hypoalbuminemia (low serum albumin) (A) cause fluid to leak into the
peritoneal cavity. Aldosterone is increased, not decreased (B); ADH (C)
contributes but is secondary; hepatic artery vasodilation (D) is part of
hyperdynamic circulation.
11.Which type of shock is most commonly associated with anaphylaxis?
• A. Hypovolemic shock
• B. Cardiogenic shock
